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Safety and Buildings Division County <br /> NV <br /> 201 W. Washington Ave., P.O. Box 7162 <br /> scons�n Madison, WI 53707-7162Site Address <br /> Department of Commerce 461 <br /> ori <br /> Sanitary Permit Application Sanitary remit Numher <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide El Check it Revision <br /> Q O� <br /> be used for second s Privacy Law,=15. IXm <br /> tna !) <br /> i. Application Information-Please Print All Information State Plan I.D.Number <br /> I d 3 oq O4 <br /> A <br /> ner's�7ame Parcel Ntunberelf /�l Dner's Mailing Address Propeny Location^ <br /> cA :4: D T3 N.R <br /> iry,State Zip Code Phone Number Lot her Block Number <br /> �,�7 Z <br /> Subdivision Name CSM Number <br /> II.Type of Building(check all that apply) ❑City <br /> I or 2 Family Dwelling-Number of Bedrooms <br /> Bedrooms <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned <br /> Nearere oad <br /> III.Type of Permit: (Check only one box online A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I ❑ New 2 Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Onl Existio 5 stem <br /> B. ❑ Check if Sanitary Permit Previously Issued Pemut Number Datc Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 ❑ Non-Pressurized In-Ground 20 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 411 Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45 11 At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30 11 Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> 7 Required Proposed Rate(Gals.1DayslSq.Ft.) (Min.finch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks COmmw Constructed Glass <br /> New F-isuna <br /> Tanks I Tanks <br /> septle or mg T <br /> Ibslnt Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum gnature MPI S Number Business Phone Number <br /> 1 71 <br /> Plum i s Add s(Street,City,Suite,Zi ode) <br /> 7 <br /> VII=U <br /> Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee('includes Groundwater Date Issued [swing a Sig w Scamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination 'R ZZ OG <br /> IX. Conditions or Approval/Reasons for Disapproval <br /> Attach complete ptam no the Coumr only)for the system on paper not less than alf2 s 11 incges to sire <br /> SBD-6398 (R. 05101) <br />